Safety Recommendations -- To the Federal Aviation Administration (FAA) to prevent Runway Incursions.

June 13, 2000,/

Summary

The information below does not include a thorough description of the Board's rationale for the safety recommendations. Safety Board staff are currently making final revisions to the recommendation letter from which the attached have been extracted. The safety recommendation letter will be distributed as soon as possible. The attached information is subject to further review and editing.

Since 1973, the Safety Board has issued numerous safety recommendations to the Federal Aviation Administration (FAA) to prevent runway incursions and other airport surface incidents, and in 1986, the Board also issued a Special Investigation Report, titled "Runway Incursions at Controlled Airports in the United States." In addition, runway incursions has been an issue on the Board's "Most Wanted" list since its inception in 1990.

In 1999, the number of runway incursions was 71 percent greater than the number in 1993, and the incursion rate per 100,000 flight operations in 1999 was 56 percent greater than in 1993, despite a slight decrease in the number of runway incursions at the end of 1999. The Board is concerned that the expected increase in air traffic activity may result in an increase in runway incursions. The Board is also concerned that runway incursions continue to occur despite the recommendations made in the Special Investigation Report, the inclusion of airport runway incursions on the "Most Wanted" list of safety issues, and additional safety recommendations issued as a result of other runway incursions.

The FAA has been addressing this issue. In October 1999, the FAA established a National Runway Safety Program to reduce the number of surface accidents and incidents. Since January 2000, the FAA has conducted 630 runway incursion safety seminars for pilots throughout the United States, and 300 more seminars are expected to be conducted by the end of June 2000. In March 2000, the FAA announced new runway safety initiatives, including more in-depth investigations of runway incursions and regional awareness meetings for pilots, airport managers, and controllers. In April 2000, the FAA established the Runway Incursions Information and Evaluation Program to gather information from pilots involved in runway incursions and determine the causes of the incursions. In addition, the FAA planned a runway safety summit for June 2000.

In response to safety recommendation A-91-29, the FAA stated that it would address the intent of the Board's recommendation to prevent runway incursions with the development of AMASS. However, the FAA later announced that AMASS would no longer be designed to prevent runway incursions, but rather would be designed to prevent runway collisions. Thus, AMASS, as currently designed, will alert the local controller of a potential collision only after a situation is already in progress, thus reducing the amount of time available to prevent a potential collision.

Following a runway incursion that occurred on April 1, 1999, at O'Hare International Airport, Chicago, Illinois, the Safety Board requested that the FAA conduct a simulation of AMASS response time using data from the incursion. According to the simulation, AMASS, as currently designed, would not have prevented the incident.

The FAA originally developed AMASS to prevent runway incursions; however, because the FAA was unable to develop an acceptable predictive warning system, AMASS' focus was changed to prevent runway collisions. Further, the current system does not appear to be able to provide sufficient warning time to prevent even some runway collisions. Providing warnings only to air traffic controllers unnecessarily increases the time to alert flight crews of a potential runway incursion or collision, as a significant amount of time is required for the controller to detect the warning, identify the nature of the problem, and determine the necessary action before attempting to establish radio contact with the flight crew.

On the basis of its investigation of several runway incidents investigated in 1999, (specifically those that occurred on April 1, 1999, at O'Hare International Airport, Chicago, Illinois; June 27, 1999, at John F. Kennedy International Airport, Jamaica, New York; November 22, 1999, at Los Angeles International Airport, Los Angeles, California; December 6, 1999, at Theodore Francis Green State Airport, Providence, Rhode Island), the Safety Board believes that an acceptable ground movement safety system should be able to provide direct warnings to flight crews and other vehicle operators of potential incursions through means such as runway edge lights and stop bars located at all runway/taxiway intersections, or by other means, such as datalink. The Board also believes that some type of ground movement safety system should be installed at all airports providing scheduled passenger service because passengers flying into and out of lower activity airports should be afforded the same level of safety as those using the busiest U.S. airports. Therefore, at all airports with scheduled passenger service, the FAA should require a ground movement safety system that will prevent runway incursions, and the system should provide a direct warning capability to flight crews. The FAA should also demonstrate through computer simulations or other means that the system will, in fact, prevent incursions.

The Board has also identified ATC operating procedures that may contribute to runway incursions and other airport surface incidents. For instance, ATC procedures should require specific clearances, rather than rely on implied clearances, for aircraft to cross runways; the FAA should discontinue the practice of allowing departing aircraft to hold on active runways at nighttime or at any time when ceiling and visibility conditions preclude arriving aircraft from seeing traffic on the runway in time to initiate a safe go-around maneuver; controllers should wait to issue a landing clearance to a following aircraft until the preceding aircraft has crossed the runway threshold; and the FAA should require the use of standard ICAO phraseology for airport surface operations.

Safety Recommendations

As a result of the investigation of several runway incidents, the National Transportation Safety Board recommends that the Federal Aviation Administration:

Require, at all airports with scheduled passenger service, a ground movement safety system that will prevent runway incursions; the system should provide a direct warning capability to flight crews. In addition, demonstrate through computer simulations or other means that the system will, in fact, prevent incursions.

Amend 14 Code of Federal Regulations (CFR) Section 91.129(i) to require that all runway crossings be authorized only by specific air traffic control clearance, and ensure that all U.S. pilots and those pilots operating under 14 CFR Part 129, and ground personnel responsible for the movement of aircraft, receive adequate notification of the change.

Amend Federal Aviation Administration Order 7110.65, "Air Traffic Control," to require that, when aircraft need to cross multiple runways, air traffic controllers issue an explicit crossing instruction for each runway after the previous runway has been crossed.

Amend Federal Aviation Administration Order 7110.65, "Air Traffic Control," Paragraph 3-9-4, "Takeoff Position Hold," to discontinue the practice of allowing departing aircraft to hold on active runways at nighttime or at any time when ceiling and visibility conditions preclude arriving aircraft from seeing traffic on the runway in time to initiate a safe go-around maneuver.

Adopt the landing clearance procedure recommended by International Civil Aviation Organization Document 4444-RAC/501, "Procedures for Air Navigation Services-Rules of the Air and Air Traffic Services," Part V, "Aerodrome Control Service," paragraph 15.2.

Amend Federal Aviation Administration Order 7110.65, "Air Traffic Control," to require the use of standard International Civil Aviation Organization phraseology (excluding conditional phraseology) or airport surface operations, and periodically emphasize to controllers the need to use this phraseology and to speak at reasonable rates when communicating with all flight crews, especially those whose primary language is not English.